| NPI | 1508020918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101264197) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CO DR46752) |
| Enumeration Date | 2008-07-15 |
| Last Update Date | 2021-06-09 |