| NPI | 1023120664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME100547) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NJ 25MA08132800) |
| 207QS0010X Family Medicine Sports Medicine (Licence: TX M2164) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: PA MD430258) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: FL ME100547) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2014-07-28 |