| NPI | 1063894590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 37689) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL37689) |
| Enumeration Date | 2015-06-21 |
| Last Update Date | 2020-08-05 |