| NPI | 1528697919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NC 2024-03236) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2024-03236) |
| 207QA0505X Family Medicine, Adult Medicine (Licence: MI 5101027559) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2025-06-10 |