| NPI | 1477212884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23216) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 001590-PA) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-12-13 |
| Last Update Date | 2023-05-09 |