| NPI | 1881167153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10089176) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 23037) |
| Enumeration Date | 2019-01-09 |
| Last Update Date | 2024-07-11 |