| NPI | 1174725303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VT 042.0012118) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: VT 042.0012118) |
| Enumeration Date | 2007-06-01 |
| Last Update Date | 2016-07-01 |