| NPI | 1093416935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: R-13095) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA DO-55446) |
| Enumeration Date | 2023-03-16 |
| Last Update Date | 2026-03-10 |