| NPI | 1902105588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: NY 00293900) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036136381) |
| 207Q00000X Family Medicine (Licence: WI 64553-20) | |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: CT 055269) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 055269) | |
| Enumeration Date | 2011-03-21 |
| Last Update Date | 2019-10-21 |