| NPI | 1821594631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 200076) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PA MD471695) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2025-04-08 |