| NPI | 1114956372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME146676) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 43563-020) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: PA MD428036) | |
| Enumeration Date | 2006-07-01 |
| Last Update Date | 2021-06-23 |