| NPI | 1336127836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2013-0032) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OR MD26058) |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2015-11-09 |