| NPI | 1376122028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-02357) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 43195) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-07 |
| Last Update Date | 2025-08-11 |