| NPI | 1902221419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208600000X Surgery (Licence: WV 28622) |
| 208D00000X General Practice (Licence: VA 0101258740) | |
| Enumeration Date | 2014-02-20 |
| Last Update Date | 2023-03-31 |