| NPI | 1801539507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MI 5101028784) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MN 75746) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-19 |
| Last Update Date | 2025-10-22 |