| NPI | 1194163378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 94146) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 68068) |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2023-07-31 |