| NPI | 1710413562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 83723) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS16978) | |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2021-09-08 |