| NPI | 1265793020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CA A156769) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD455817) |
| 207Q00000X Family Medicine (Licence: PA MT200938) | |
| Enumeration Date | 2012-06-07 |
| Last Update Date | 2019-11-06 |