| NPI | 1366980559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 34.014569CTR) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT019239) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-02-07 |
| Last Update Date | 2025-10-21 |