| NPI | 1356602114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 61152-20) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WI 61152-20) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2023-09-01 |