| NPI | 1073923496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA OS017810) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS017810) |
| 207Q00000X Family Medicine (Licence: PA OT015777) | |
| Enumeration Date | 2014-05-07 |
| Last Update Date | 2022-08-26 |