| NPI | 1306165097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA MD.205203) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 28991) |
| 207Q00000X Family Medicine (Licence: IL 036139441) | |
| 207Q00000X Family Medicine (Licence: NM MD2019-0172) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-05-20 |
| Last Update Date | 2019-07-12 |