| NPI | 1417512070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2022025502) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: LA 309446) |
| Enumeration Date | 2019-05-08 |
| Last Update Date | 2023-09-20 |