| NPI | 1255504254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 11603) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MT 11603) |
| 208D00000X General Practice (Licence: MT 11603) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: MT 11603) | |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2010-02-05 |