| NPI | 1508202565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX Q5921) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP1-0047978) |
| Enumeration Date | 2013-05-17 |
| Last Update Date | 2019-08-22 |