| NPI | 1205070703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2012-00747) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2012-00747) |
| Enumeration Date | 2009-04-28 |
| Last Update Date | 2021-09-01 |