| NPI | 1649733254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WA OP61079628) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 307681) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-10 |
| Last Update Date | 2023-03-30 |