| NPI | 1003992470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 62633341205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 6263334-1205) |
| 207QS0010X Family Medicine Sports Medicine (Licence: UT 62633341205) | |
| Enumeration Date | 2006-10-28 |
| Last Update Date | 2015-01-15 |