| NPI | 1407476450 |
|---|---|
| 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: MN 71713) |
| Enumeration Date | 2020-04-20 |
| Last Update Date | 2022-12-13 |