| NPI | 1568873875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PA MD458267) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301104741) |
| Enumeration Date | 2014-05-09 |
| Last Update Date | 2023-08-29 |