| NPI | 1356548267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 036.124288) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2006015933) |
| Enumeration Date | 2007-07-03 |
| Last Update Date | 2012-02-08 |