| NPI | 1063501922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NV 14002) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301047795) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301047795) | |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2011-10-04 |