| NPI | 1164788501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NJ 25MB09913200) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS017463) |
| Enumeration Date | 2012-04-10 |
| Last Update Date | 2020-10-15 |