| NPI | 1306343603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: IL 336.119768) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.072854) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-12 |
| Last Update Date | 2022-08-16 |