| NPI | 1366805210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301110124) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI W200603847817) |
| Enumeration Date | 2016-03-29 |
| Last Update Date | 2019-05-14 |