| NPI | 1053632018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 2819) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116022730) |
| 207Q00000X Family Medicine (Licence: SC 35703) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: SC 35703) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TN 2819) | |
| Enumeration Date | 2010-06-14 |
| Last Update Date | 2015-06-08 |