NPI | 1902486921 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102207551) |
Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102207551) |
390200000X Student in an Organized Health Care Education/Training Program | |
Enumeration Date | 2021-04-13 |
Last Update Date | 2024-02-16 |