| NPI | 1619101052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MA 254419) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: FL 113368) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA 241172) | |
| Enumeration Date | 2009-05-13 |
| Last Update Date | 2021-04-22 |