| NPI | 1104302231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NY 338482) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207R00000X Internal Medicine (Licence: CA 173565) | |
| 261QP2300X Clinic/Center, Primary Care (Licence: CA 173565) | |
| Enumeration Date | 2018-07-11 |
| Last Update Date | 2026-03-31 |