| NPI | 1134568918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2015032303) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2013017875) |
| Enumeration Date | 2013-06-14 |
| Last Update Date | 2018-10-09 |