| NPI | 1972186732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 22237) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 22237) |
| Enumeration Date | 2021-04-29 |
| Last Update Date | 2024-07-18 |