| NPI | 1902594229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID 7281214) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA WDL3BR75C13B) |
| Enumeration Date | 2023-04-25 |
| Last Update Date | 2026-07-02 |