| NPI | 1760226716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 101347-851) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125-084945) |
| Enumeration Date | 2024-06-24 |
| Last Update Date | 2025-07-01 |