| NPI | 1770248619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: OK 8562) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OK 8562) |
| 208000000X Pediatrics (Licence: OK 8562) | |
| Enumeration Date | 2021-11-05 |
| Last Update Date | 2026-07-08 |