| NPI | 1396486742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NE 35990) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: NE 35990) | |
| Enumeration Date | 2022-04-07 |
| Last Update Date | 2024-09-05 |