| NPI | 1427636034 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102208567) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 34.017747) | |
| Enumeration Date | 2021-04-02 | 
| Last Update Date | 2025-10-27 |