| NPI | 1164915633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS020327) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT018631) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: PA OT018631) | |
| Enumeration Date | 2018-06-10 |
| Last Update Date | 2022-07-25 |