| NPI | 1003107855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OK 5219) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS017248) |
| Enumeration Date | 2011-04-27 |
| Last Update Date | 2015-08-03 |