| NPI | 1508156571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207XX0005X Orthopaedic Surgery Sports Medicine (Licence: NY 282757) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2011-04-12 |
| Last Update Date | 2021-03-02 |