| NPI | 1790170587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: VA 0102205561) |
| Additional Taxonomies | 2080S0010X Pediatrics, Sports Medicine (Licence: PA OT018272) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-03-30 |
| Last Update Date | 2020-05-07 |