| NPI | 1043955909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 201-T1) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 108574-146) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-04 |
| Last Update Date | 2022-06-27 |