| NPI | 1619358710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2018-00531) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116028181) |
| Enumeration Date | 2015-06-15 |
| Last Update Date | 2026-08-25 |