| NPI | 1700400470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NY 324893) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 324893) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT020007) | |
| Enumeration Date | 2020-05-29 |
| Last Update Date | 2024-06-24 |