| NPI | 1205399169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 56833) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 56833) |
| Enumeration Date | 2019-04-08 |
| Last Update Date | 2022-08-15 |