| NPI | 1255017331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS026173) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT022718) |
| Enumeration Date | 2023-06-23 |
| Last Update Date | 2026-08-11 |