| NPI | 1104051481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 201301281) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 34343) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH N/A) | |
| Enumeration Date | 2009-05-15 |
| Last Update Date | 2020-10-25 |