| NPI | 1124222351 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ND 10697) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301083834) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301083834) | |
| 207Q00000X Family Medicine (Licence: ND PT 10697) | |
| Enumeration Date | 2007-06-12 |
| Last Update Date | 2011-11-30 |