| NPI | 1366881112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101024437) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 290901) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 5101024437) | |
| Enumeration Date | 2013-06-14 |
| Last Update Date | 2024-06-15 |