| NPI | 1235490038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: WA MD60771757) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD458625) |
| 207Q00000X Family Medicine (Licence: WA MD600771757) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: PA MD458625) | |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2019-08-14 |