| NPI | 1164835195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: TX R2839) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT206946) |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2017-10-13 |