| NPI | 1164764684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 272651) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MA 272651) |
| Enumeration Date | 2013-03-22 |
| Last Update Date | 2018-05-14 |