| NPI | 1861733172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WA OP60815058) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OH 34.011960) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-12 |
| Last Update Date | 2021-10-22 |