| NPI | 1306919907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 23060) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 52096) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.133627) | |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2023-03-07 |