| NPI | 1114556594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2020010224) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2023-04-10 |