| NPI | 1750098901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 1750899001) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 2202034161) |
| Enumeration Date | 2022-10-27 |
| Last Update Date | 2023-07-03 |