| NPI | 1821431859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 81755) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 81755) |
| 207Q00000X Family Medicine (Licence: FL OS12908) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS12908) | |
| Enumeration Date | 2013-04-09 |
| Last Update Date | 2025-01-29 |