| NPI | 1477058949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2020011225) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.072855) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2021-08-05 |