| NPI | 1003565953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 17509) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: WI 83001-20) | |
| Enumeration Date | 2022-03-19 |
| Last Update Date | 2025-07-02 |