| NPI | 1588122667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 2024-00548) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: VA 0102209345) | |
| Enumeration Date | 2019-03-07 |
| Last Update Date | 2025-09-10 |