| NPI | 1568017218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 35812R) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 15068-I) |
| Enumeration Date | 2019-08-08 |
| Last Update Date | 2023-03-05 |