| NPI | 1578293635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 81202) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT021968) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2025-09-17 |