| NPI | 1275524779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NV 25404) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 12979A) |
| 207Q00000X Family Medicine (Licence: CO 44394) | |
| 207Q00000X Family Medicine (Licence: TX L0959) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: CO 44394) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX L0959) | |
| Enumeration Date | 2005-11-03 |
| Last Update Date | 2024-10-29 |