| NPI | 1164083192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL DO.3248) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT020391) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-20 |
| Last Update Date | 2023-06-06 |