| NPI | 1639699200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 71579-21) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 66646) |
| 207Q00000X Family Medicine (Licence: WV 3356) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-23 |
| Last Update Date | 2020-06-19 |