| NPI | 1124432430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MO 2016018274) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2016018274) |
| Enumeration Date | 2014-06-13 |
| Last Update Date | 2024-11-12 |