| NPI | 1538819883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2026-03903) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: NC 2026-03903) | |
| Enumeration Date | 2022-03-28 |
| Last Update Date | 2026-09-11 |