| NPI | 1629633060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX S8370) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL OS18309) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 2083P0011X Preventive Medicine Undersea and Hyperbaric Medicine (Licence: FL 0S18309) | |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2023-12-22 |