| NPI | 1730593708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: FL ME135790) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL TRN25256) |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2018-06-12 |