| NPI | 1154984904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 75119) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 82695-20) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-17 |
| Last Update Date | 2023-09-21 |