| NPI | 1063862977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 101-T2) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 101-T1) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2017-07-31 |