| NPI | 1780113886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 7286321) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125071136) |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2020-08-24 |