| NPI | 1770996779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX S6095) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA 20A14540) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2026-07-09 |