| NPI | 1710446794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 93261) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2022-01387) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-18 |
| Last Update Date | 2025-04-28 |