| NPI | 1205015930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX M8189) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX M8189) |
| Enumeration Date | 2007-10-30 |
| Last Update Date | 2014-09-26 |