| NPI | 1356937205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10085266) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WA OP.61583423) |
| Enumeration Date | 2020-12-15 |
| Last Update Date | 2026-03-08 |