| NPI | 1225241573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57-012557) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101246207) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2012-01-12 |