| NPI | 1942527932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080S0010X Pediatrics, Sports Medicine (Licence: TN 50353) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2010-04-29 |
| Last Update Date | 2014-06-19 |