| NPI | 1073834404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX V3047) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 32892) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: GA 071595) | |
| Enumeration Date | 2010-06-21 |
| Last Update Date | 2024-09-23 |