| NPI | 1023679883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 77247) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4351044269) |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2022-07-28 |