| NPI | 1023071727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101012620) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101012620) |
| 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: MI 5101012620) | |
| Enumeration Date | 2006-04-11 |
| Last Update Date | 2017-12-05 |