| NPI | 1275747925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301082118) |
| Additional Taxonomies | 2080S0010X Pediatrics, Sports Medicine (Licence: CT 049446) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2022-04-13 |