| NPI | 1760942866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WA 61498172) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 33227) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-23 |
| Last Update Date | 2025-06-24 |