| NPI | 1790102184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME156035) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: WV 26661) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2022-07-18 |