| NPI | 1104203496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: VA 0101266188) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2018-01738) |
| Enumeration Date | 2015-05-06 |
| Last Update Date | 2020-09-03 |