| NPI | 1245895507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: IL 036.170584) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: IL 125.078956) | |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2024-07-17 |