| NPI | 1255785465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080S0010X Pediatrics Sports Medicine (Licence: MN 70404) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: MN 70404) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-04-14 |
| Last Update Date | 2023-06-13 |