| NPI | 1164715769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207XX0005X Orthopaedic Surgery Sports Medicine (Licence: OH 35.139815) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT223610) |
| 208D00000X General Practice (Licence: NE 27335) | |
| Enumeration Date | 2011-05-16 |
| Last Update Date | 2022-09-24 |