| NPI | 1902465305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 4301507384) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 4301507384) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2022-08-23 |