| NPI | 1134191257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2010011161) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: KS 0434967) |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2017-10-27 |