| NPI | 1699478255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX 1699478255) |
| Enumeration Date | 2023-03-23 |
| Last Update Date | 2026-05-17 |