| NPI | 1003086521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD157616) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL none) |
| 207Q00000X Family Medicine (Licence: AL 29467) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: AL 29467) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OR MD157616) | |
| Enumeration Date | 2008-03-11 |
| Last Update Date | 2021-06-03 |