| NPI | 1164981015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.146028) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57.247181) |
| Enumeration Date | 2019-03-19 |
| Last Update Date | 2022-07-16 |