| NPI | 1104313634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 009179) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT18912) |
| Enumeration Date | 2018-04-19 |
| Last Update Date | 2021-09-17 |