| NPI | 1265151419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 83759-20) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 9991-851) |
| Enumeration Date | 2022-08-23 |
| Last Update Date | 2025-01-22 |