| NPI | 1669052007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2025-02289) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TN 71329) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-09 |
| Last Update Date | 2025-09-22 |