| NPI | 1649972944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: MS 33705) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MS 33705) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2026-03-16 |