| NPI | 1871881052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: ID O-0694) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 8974078-1204) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2019-02-22 |