| NPI | 1942648225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 34.018745) |
| Additional Taxonomies | 207RS0010X Internal Medicine, Sports Medicine (Licence: GA 78396) |
| 207RS0010X Internal Medicine, Sports Medicine (Licence: MO 2019045767) | |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2026-07-27 |