| NPI | 1164541637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2008-01732) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2008-01732) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.089845) | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301084246) | |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2026-05-06 |