| NPI | 1073703153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: WI 54203-020) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 51582) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-07-26 |
| Last Update Date | 2021-05-14 |