| NPI | 1659892693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1171) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 14443-I) |
| Enumeration Date | 2017-06-29 |
| Last Update Date | 2019-09-23 |