| NPI | 1215916119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9701751) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9701751) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2023-04-12 |