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 |