| NPI | 1982966479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2020-00456) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 51212) |
| 207Q00000X Family Medicine (Licence: LA 206248) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-06-12 |
| Last Update Date | 2021-08-10 |