| NPI | 1124507439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 86593) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 7185-851) |
| Enumeration Date | 2018-08-08 |
| Last Update Date | 2021-09-23 |