| NPI | 1164867347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 53485) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 272256) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NY 272256) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-05-01 |
| Last Update Date | 2021-06-10 |