| NPI | 1538861919 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 17564I) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2023-03-20 | 
| Last Update Date | 2025-07-30 |