| NPI | 1699254656 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 22930) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15947-I) |
| Enumeration Date | 2018-08-10 |
| Last Update Date | 2022-08-13 |