| NPI | 1689202491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC RTL23-0644) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY R5434) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-03-28 |
| Last Update Date | 2023-07-02 |