| NPI | 1194088658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 61879) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX R4384) | |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2022-07-21 |