| NPI | 1912584954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: TX W5285) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OR 1912584954) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-25 |
| Last Update Date | 2026-05-07 |