| NPI | 1972098499 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: KY R3915) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 2021039572) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2025-06-30 |