NPI | 1255793261 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 66357) |
Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 54825) |
Enumeration Date | 2016-03-28 |
Last Update Date | 2020-09-03 |