| NPI | 1205241866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 007353) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10050782) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2020-08-17 |