| NPI | 1710674510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A205117) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CA A205117) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME182134) | |
| Enumeration Date | 2023-04-20 |
| Last Update Date | 2026-06-08 |