| NPI | 1578188397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101278307) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116034071) |
| Enumeration Date | 2020-06-09 |
| Last Update Date | 2023-07-03 |