| NPI | 1962018671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 58.032115) |
| Enumeration Date | 2020-09-17 |
| Last Update Date | 2024-06-27 |