| NPI | 1063040475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 06262) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: OH 34.017377) | |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2026-01-30 |