| NPI | 1871079640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QX0100X Clinic/Center, Occupational Medicine (Licence: CA A192257) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2018011141) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX 2018011141) | |
| Enumeration Date | 2018-07-16 |
| Last Update Date | 2024-02-02 |