| NPI | 1104038629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 4301081773) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: OH 35.088761) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2021-10-22 |