| NPI | 1790989721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: OH 35-091584) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57010570) |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2013-11-27 |