| NPI | 1053671743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME165672) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35123035) |
| 207Q00000X Family Medicine (Licence: MO 2020029935) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-05-29 |
| Last Update Date | 2024-02-23 |