| NPI | 1376036970 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35.143240) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125.072954) |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2021-09-20 |