| NPI | 1578097788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS17734) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: VA 0102205568) | |
| Enumeration Date | 2017-04-13 |
| Last Update Date | 2026-09-04 |