| NPI | 1164918645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS16201) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL UO5707) |
| Enumeration Date | 2018-07-08 |
| Last Update Date | 2020-07-06 |