| NPI | 1487157236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO224684) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA OP61335543) |
| Enumeration Date | 2018-03-16 |
| Last Update Date | 2025-09-04 |