| NPI | 1235713223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics Sports Medicine (Licence: TX V9292) |
| Additional Taxonomies | 2080S0010X Pediatrics Sports Medicine (Licence: OH 35.150573) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-05-06 |
| Last Update Date | 2025-07-23 |