| NPI | 1710493739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: FL UO5588) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL UO5588) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL UO5588) | |
| Enumeration Date | 2017-12-28 |
| Last Update Date | 2022-09-21 |