| NPI | 1003115072 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2083P0901X Preventive Medicine, Public Health & General Preventive Medicine (Licence: PA 35-05-6433)  | 
| Additional Taxonomies | 2083P0901X Preventive Medicine, Public Health & General Preventive Medicine (Licence: OH 35-05-6433)  | 
| 2083S0010X Preventive Medicine, Sports Medicine (Licence: WI 41810-020)  | |
| Enumeration Date | 2011-03-16 | 
| Last Update Date | 2011-03-16 |