NPI | 1104492560 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101028046) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014925) |
Enumeration Date | 2021-05-27 |
Last Update Date | 2024-07-03 |