| NPI | 1730808395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 23145) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15878-I) |
| Enumeration Date | 2022-08-25 |
| Last Update Date | 2023-03-15 |