| NPI | 1467078576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA MT234993) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4351046706) |
| 207Q00000X Family Medicine (Licence: MI 4351046706) | |
| 207Q00000X Family Medicine (Licence: MI 4301509321) | |
| Enumeration Date | 2020-06-24 |
| Last Update Date | 2025-07-17 |