| NPI | 1295931962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 63808) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD427827) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: PA MD427827) | |
| Enumeration Date | 2007-06-21 |
| Last Update Date | 2018-06-21 |