| NPI | 1255829966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: FL ACN1418) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: NH 25173) |
| 363A00000X Physician Assistant (Licence: MO 2019045102) | |
| 363A00000X Physician Assistant (Licence: IN CV2000213) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2024-12-07 |