| NPI | 1376115543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 023119) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 000291) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-07-15 |
| Last Update Date | 2023-02-23 |