| NPI | 1174151237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-03218) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2021-03218) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2023-05-22 |