NPI | 1376938159 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME141407) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
Enumeration Date | 2015-03-30 |
Last Update Date | 2020-02-05 |