| NPI | 1104211986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 295422) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 1015332) |
| 207Q00000X Family Medicine (Licence: GA 87745) | |
| 207Q00000X Family Medicine (Licence: TX V1769) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-30 |
| Last Update Date | 2025-04-11 |