| NPI | 1679197404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23088) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15368-I) |
| Enumeration Date | 2020-06-08 |
| Last Update Date | 2023-02-24 |