| NPI | 1366970576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 73923) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125070421) |
| Enumeration Date | 2017-06-01 |
| Last Update Date | 2025-01-03 |