| NPI | 1972093219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: FL ME150805) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: GA 109813) | |
| Enumeration Date | 2018-05-12 |
| Last Update Date | 2026-06-17 |