| NPI | 1053725887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MA 270599) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: ZZ 15125) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2018-03-17 |