| NPI | 1134824634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-04051) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC MORG-6NR7JY) |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2026-08-05 |