| NPI | 1285139410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-01643) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 315392) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-29 |
| Last Update Date | 2024-09-16 |