| NPI | 1720442494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA A153909) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 63751) |
| Enumeration Date | 2016-04-08 |
| Last Update Date | 2019-03-22 |