| NPI | 1336766872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 81312-20) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MN 31198) |
| Enumeration Date | 2020-07-01 |
| Last Update Date | 2026-09-23 |