| NPI | 1518542422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1688) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 24170) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 16829-1) | |
| Enumeration Date | 2021-03-11 |
| Last Update Date | 2025-07-28 |