| NPI | 1326031014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS10357) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2005-08-26 |
| Last Update Date | 2023-06-13 |