| NPI | 1801462064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 24303) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PR 1460-PA) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 15740-I) | |
| Enumeration Date | 2021-05-28 |
| Last Update Date | 2025-03-21 |