| NPI | 1205856705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME96098) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 36116409) |
| 207Q00000X Family Medicine (Licence: FL ME 96098) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2009-01-27 |