| NPI | 1740922137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2023-02823) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC RTL22-0772) |
| Enumeration Date | 2022-04-07 |
| Last Update Date | 2026-07-27 |