| NPI | 1255913893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125077505) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.077505) |
| Enumeration Date | 2021-04-23 |
| Last Update Date | 2021-04-29 |