| NPI | 1841562956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 165213) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MA 882334) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2209) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-02-04 |
| Last Update Date | 2021-09-13 |