| NPI | 1710566195 |
|---|---|
| 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: NY 330858) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: CT 77510) | |
| Enumeration Date | 2021-04-05 |
| Last Update Date | 2024-08-06 |