| NPI | 1548990336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 4280) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WV ED1145A) |
| Enumeration Date | 2022-06-14 |
| Last Update Date | 2026-04-30 |