| NPI | 1184036774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 55318) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ R74329) |
| Enumeration Date | 2014-05-30 |
| Last Update Date | 2023-05-31 |