| NPI | 1811579782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NC 2024-00533) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 302761) |
| Enumeration Date | 2021-04-21 |
| Last Update Date | 2025-07-15 |