| NPI | 1972469781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 125.088981) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: DC NA) |
| Enumeration Date | 2025-12-25 |
| Last Update Date | 2026-07-01 |