| NPI | 1619619764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MO 2026004420) |
| Additional Taxonomies | 208D00000X General Practice (Licence: LA 338892) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-09 |
| Last Update Date | 2026-04-06 |