| NPI | 1104357714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD61204134) |
| 207Q00000X Family Medicine (Licence: OR MD191309) | |
| Enumeration Date | 2017-03-24 |
| Last Update Date | 2021-09-02 |