| NPI | 1619768868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO TL.0011031) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO TL.0011031) |
| Enumeration Date | 2025-05-16 |
| Last Update Date | 2025-06-25 |