| NPI | 1558724377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME137838) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10055923) |
| Enumeration Date | 2016-03-30 |
| Last Update Date | 2019-09-18 |