| NPI | 1720399058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 56220) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 56220) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 40952) | |
| Enumeration Date | 2010-07-01 |
| Last Update Date | 2014-09-09 |