| NPI | 1922700533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT023480) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0102209607) |
| 207Q00000X Family Medicine (Licence: PA OT023480) | |
| 208D00000X General Practice (Licence: MD H0104522) | |
| 207Q00000X Family Medicine (Licence: PA OS025237) | |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2025-09-11 |