| NPI | 1679221287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1422) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 22656) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15610-I) | |
| Enumeration Date | 2022-03-13 |
| Last Update Date | 2022-09-15 |