| NPI | 1164884904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 54396) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 008238) |
| 207Q00000X Family Medicine (Licence: ND 15805) | |
| Enumeration Date | 2016-03-22 |
| Last Update Date | 2024-10-02 |