| NPI | 1508414921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 319935) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 29873) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN29873) | |
| Enumeration Date | 2019-08-28 |
| Last Update Date | 2023-11-29 |