| NPI | 1669163614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 81984) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125.081574) |
| Enumeration Date | 2023-05-18 |
| Last Update Date | 2026-05-02 |