| NPI | 1417245101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA C152340) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA 152340) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT200277) | |
| Enumeration Date | 2011-07-14 |
| Last Update Date | 2020-10-29 |