| NPI | 1619177789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60097718) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R7985) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA R7985) | |
| Enumeration Date | 2007-07-18 |
| Last Update Date | 2012-10-10 |