| NPI | 1104302231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: CA 173565) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CA 173565) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2021-08-10 |