| NPI | 1912177759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT205507) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CA A101748) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: IL 125.080536) | |
| Enumeration Date | 2008-03-07 |
| Last Update Date | 2022-08-11 |