| NPI | 1053755306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101256670) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2013-04-17 |
| Last Update Date | 2023-12-08 |