| NPI | 1134654452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MD H0091778) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT017720) |
| Enumeration Date | 2017-04-24 |
| Last Update Date | 2021-08-10 |