| NPI | 1659012169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 4301512090) |
| Enumeration Date | 2022-04-06 |
| Last Update Date | 2026-03-30 |