| NPI | 1154684777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: OH 126223) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MI 4301100757) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301100757) | |
| Enumeration Date | 2012-06-19 |
| Last Update Date | 2015-06-24 |