| NPI | 1366886053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 58494) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO TL.0006261) |
| Enumeration Date | 2013-04-24 |
| Last Update Date | 2018-05-03 |