| NPI | 1700237161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 05380) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT017422) |
| Enumeration Date | 2016-06-28 |
| Last Update Date | 2021-05-28 |