| NPI | 1154619682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 257971) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301098053) |
| Enumeration Date | 2011-07-18 |
| Last Update Date | 2018-10-02 |