| NPI | 1770264376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 37036-R) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 16790) |
| Enumeration Date | 2023-07-26 |
| Last Update Date | 2025-05-09 |