| NPI | 1386160265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 21927) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14395I) |
| Enumeration Date | 2017-08-22 |
| Last Update Date | 2020-11-09 |