| NPI | 1790133627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MD467581) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT210998) |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2019-07-05 |