| NPI | 1043282767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS14442) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NH 13446) |
| 207QS0010X Family Medicine Sports Medicine (Licence: NH 13446) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: VA 0102201136) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: ME 2066) | |
| Enumeration Date | 2006-02-06 |
| Last Update Date | 2022-03-14 |