| 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 |