| NPI | 1154779007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 65311) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4351042487) |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2019-04-30 |