| NPI | 1487383089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME175924) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 35794) |
| Enumeration Date | 2022-06-08 |
| Last Update Date | 2025-09-15 |