| NPI | 1114800018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY P135598) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PA MD490485) |
| Enumeration Date | 2025-07-28 |
| Last Update Date | 2025-07-28 |