| NPI | 1679203954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MI 4301515755) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4351049753) |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2025-11-20 |