| NPI | 1104514884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-00479) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC RTL23-0106) |
| Enumeration Date | 2023-05-01 |
| Last Update Date | 2025-03-01 |