| NPI | 1952044927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61678884) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 75437) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-18 |
| Last Update Date | 2025-06-30 |