| NPI | 1306133129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MO 2015029582) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL33845) |
| 207Q00000X Family Medicine (Licence: MO 2015029582) | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2019-01-14 |