| NPI | 1073900296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD60984012) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: UT 10094322-1205) | |
| Enumeration Date | 2015-04-26 |
| Last Update Date | 2021-01-15 |