| NPI | 1104815505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0014X Pain Medicine Interventional Pain Medicine (Licence: TX L3128) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX L3128) |
| 207QS0010X Family Medicine Sports Medicine (Licence: TX L3128) | |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2013-12-02 |