| NPI | 1003178013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2014-0755) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NM RS2012-0466) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OK 32151) | |
| Enumeration Date | 2012-06-14 |
| Last Update Date | 2016-05-24 |