| NPI | 1679032445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: OH 35.148891) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NJ 25MA11211300) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-19 |
| Last Update Date | 2024-03-28 |