| NPI | 1487148672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME157334) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME157334) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301115789) | |
| Enumeration Date | 2018-06-20 |
| Last Update Date | 2023-08-14 |