| NPI | 1891322137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP20093544) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PA MD486199) |
| Enumeration Date | 2020-03-25 |
| Last Update Date | 2025-06-30 |