| NPI | 1770957854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60734082) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 64870-20) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 64870-20) | |
| Enumeration Date | 2015-11-30 |
| Last Update Date | 2022-07-21 |