| NPI | 1508438649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23852) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15967-I) |
| 363AM0700X Physician Assistant, Medical (Licence: PR 1043) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-07-16 |
| Last Update Date | 2024-05-26 |