| NPI | 1124339460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 8591638-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 8591638-1204) |
| 208D00000X General Practice (Licence: MI 5101018672) | |
| Enumeration Date | 2010-07-01 |
| Last Update Date | 2021-09-08 |