| NPI | 1902193782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS16842) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0102203202) |
| 208D00000X General Practice (Licence: VA 0102203202) | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2020-09-02 |