| NPI | 1972166890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207ZP0102X Pathology, Anatomic Pathology & Clinical Pathology (Licence: CA C198030) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 32753) |
| 208D00000X General Practice (Licence: NE 32753) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2025-05-23 |