| NPI | 1104323203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 76379) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 89053) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-06 |
| Last Update Date | 2024-04-15 |