| NPI | 1467104208 |
|---|---|
| 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: MO 2022002147) |
| 363A00000X Physician Assistant (Licence: MO 2022002147) | |
| Enumeration Date | 2022-01-24 |
| Last Update Date | 2024-04-16 |