| NPI | 1356736417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 83071) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD182193) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-05 |
| Last Update Date | 2019-07-24 |