| NPI | 1700316544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD201218) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT214250) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2020-08-25 |