| NPI | 1659067874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MO 2024049983) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: MO 2024049983) | |
| Enumeration Date | 2023-04-12 |
| Last Update Date | 2026-06-04 |