| NPI | 1114412772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116031820) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: VA 0116031820) |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2018-08-08 |