| NPI | 1912493990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102206540) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT018355) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-07-02 |
| Last Update Date | 2021-07-21 |