| NPI | 1073207064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: VA 0102210148) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116037899) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116037899) | |
| Enumeration Date | 2023-06-05 |
| Last Update Date | 2026-05-18 |