| NPI | 1508021726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID M-11018) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 52403-020) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 2723) | |
| Enumeration Date | 2008-07-28 |
| Last Update Date | 2010-12-30 |