| NPI | 1164608113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX S0344) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2010-01146) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2010-01146) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WV 27244) | |
| Enumeration Date | 2008-01-20 |
| Last Update Date | 2019-02-11 |