| NPI | 1871343277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-03538) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC RTL24-0765) | |
| Enumeration Date | 2024-03-26 |
| Last Update Date | 2026-01-17 |