| NPI | 1205574456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 86071) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125080142) |
| Enumeration Date | 2022-05-26 |
| Last Update Date | 2025-10-27 |