| NPI | 1740735828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY P00712) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PA MD457121) |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2016-08-18 |