| NPI | 1225568462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NC 00887) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 87067) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NE 1976) | |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2024-05-30 |