| NPI | 1629770383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.089034) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: IL 125.089034) | |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2026-07-13 |