| NPI | 1114957362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-0459) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: ID MR0875) |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2019-11-19 |