| NPI | 1841929692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 36881) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: NE 36881) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2025-08-06 |