| NPI | 1689052789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MI 4301108547) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 4301108547) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301108547) | |
| Enumeration Date | 2015-05-11 |
| Last Update Date | 2019-11-04 |