| NPI | 1285088799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WI 9037-851) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1756-39) |
| Enumeration Date | 2016-04-20 |
| Last Update Date | 2021-06-08 |