| NPI | 1972949725 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A142463) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 63364) |
| Enumeration Date | 2013-05-21 |
| Last Update Date | 2018-07-13 |