| NPI | 1356800742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 91704) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 11837364-1205) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2025-07-22 |