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 |