| NPI | 1003378092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 38910) |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2022-05-11 |