| NPI | 1174608111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KS 04-32151) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2012028256) |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2022-01-04 |