| NPI | 1487235818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101278312) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 0000000) |
| Enumeration Date | 2021-04-17 |
| Last Update Date | 2024-01-22 |