| NPI | 1285167759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: LA 327774) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2021-10-13 |