| NPI | 1881335180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 85764-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125080610) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-02 |
| Last Update Date | 2025-07-22 |