| NPI | 1174839161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS12241) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102204383) |
| Enumeration Date | 2010-08-27 |
| Last Update Date | 2020-08-27 |