| NPI | 1447413323 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 709)  | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2008-07-09 | 
| Last Update Date | 2025-09-05 |