| NPI | 1134488539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 49328) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AL MD.34424) |
| Enumeration Date | 2012-05-07 |
| Last Update Date | 2020-03-12 |