| NPI | 1508506924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center Urgent Care (Licence: CA 191400) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-04-01 |
| Last Update Date | 2024-09-18 |