| NPI | 1174880538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 62267) |
| Additional Taxonomies | 208600000X Surgery (Licence: NH 18287) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-04-23 |
| Last Update Date | 2019-01-28 |