| NPI | 1134571862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NE 2256) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R10702) |
| 207Q00000X Family Medicine (Licence: IA DO-05199) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: IA DO-05199) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-06 |
| Last Update Date | 2020-12-28 |