| NPI | 1154715142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX S3986) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 69602-20) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-27 |
| Last Update Date | 2020-06-04 |