| NPI | 1780189076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO 207Q00000X) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO Pending) |
| Enumeration Date | 2018-03-28 |
| Last Update Date | 2019-11-05 |