| NPI | 1205396124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NY 319185) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.074250) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-25 |
| Last Update Date | 2023-10-03 |