| NPI | 1114506755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 6728) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: KY 05636) | |
| Enumeration Date | 2021-04-02 |
| Last Update Date | 2026-06-10 |