| NPI | 1588927552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: CA 20A13729) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA ot014708) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NJ P13-00487) | |
| Enumeration Date | 2012-06-24 |
| Last Update Date | 2018-03-17 |