| NPI | 1356970594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 16763-I) |
| 363LF0000X Nurse Practitioner, Family (Licence: FL 11006535) | |
| Enumeration Date | 2020-04-08 |
| Last Update Date | 2024-04-08 |