| NPI | 1902930811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: DE C1-0008350) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101240716) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: DE C7-0003034) | |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2015-04-09 |