| NPI | 1285910133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 47348) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 3838-850) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 57426-20) | |
| Enumeration Date | 2011-10-24 |
| Last Update Date | 2013-08-13 |