| NPI | 1043637119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 301182) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207QS0010X Family Medicine Sports Medicine (Licence: LA 301182) | |
| Enumeration Date | 2014-03-26 |
| Last Update Date | 2022-07-20 |