| NPI | 1114961166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: ID O-157) |
| Additional Taxonomies | 204C00000X Neuromusculoskeletal Medicine, Sports Medicine (Licence: ID O-157) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: ID 0-157) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2014-09-30 |