| NPI | 1528299542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: UT 9006473-1204) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO TL3403) |
| Enumeration Date | 2009-08-07 |
| Last Update Date | 2015-02-09 |