| NPI | 1821619222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX W6558) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101274795) |
| Enumeration Date | 2020-04-27 |
| Last Update Date | 2026-06-30 |