| NPI | 1508431107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-02979) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL 33001) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 33001) | |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2024-10-10 |