| NPI | 1578096731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 305714) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 295202) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-05 |
| Last Update Date | 2024-07-03 |