| NPI | 1831650373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 335544) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: MS 29507) | |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2024-07-12 |