| NPI | 1407551088 |
|---|---|
| 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: NC 2025-02327) |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2025-08-15 |