| NPI | 1992094908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2012030855) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2012030855) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-03-30 |
| Last Update Date | 2021-06-11 |