| NPI | 1356570469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 73382) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO BS57416632009017062) |
| Enumeration Date | 2009-07-09 |
| Last Update Date | 2015-06-15 |