| NPI | 1366006314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 05526) |
| Additional Taxonomies | 208D00000X General Practice (Licence: IL 036.160249) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-25 |
| Last Update Date | 2026-02-16 |