| NPI | 1770024986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: AZ 56077) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: AZ 56077) |
| 208D00000X General Practice (Licence: MO 2022026093) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2022026093) | |
| Enumeration Date | 2017-03-20 |
| Last Update Date | 2023-08-07 |