| NPI | 1992231294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 301528) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT212736) |
| Enumeration Date | 2017-05-04 |
| Last Update Date | 2019-12-15 |