| NPI | 1952838351 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: KY 54170) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301112486) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN27380) | |
| Enumeration Date | 2017-05-16 |
| Last Update Date | 2022-11-22 |