| NPI | 1780189514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 86498) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: GA 86498) | |
| Enumeration Date | 2018-03-26 |
| Last Update Date | 2023-02-28 |