| NPI | 1003202847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102204926) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102204926) |
| Enumeration Date | 2015-04-08 |
| Last Update Date | 2021-06-16 |