NPI | 1407141948 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD60358064) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
207Q00000X Family Medicine (Licence: WI 62508-20) | |
Enumeration Date | 2011-06-13 |
Last Update Date | 2015-07-10 |