| NPI | 1619135761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 55379) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 106011) |
| 207Q00000X Family Medicine (Licence: MI 4301097920) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT102803) | |
| Enumeration Date | 2008-05-27 |
| Last Update Date | 2020-08-18 |