| NPI | 1104189992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: CT 054098) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 719291062) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2015-07-14 |