| NPI | 1053544437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS016474) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL UO 2271) |
| 207Q00000X Family Medicine (Licence: PA OS016474) | |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2017-01-20 |