| NPI | 1407415797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 95418) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME147385) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2023-07-18 |