| NPI | 1023701489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: DC MD600005701) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME175687) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN37595) | |
| Enumeration Date | 2023-06-01 |
| Last Update Date | 2026-07-02 |