| NPI | 1346779477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 40718) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 85773) |
| 207Q00000X Family Medicine (Licence: SC LL40718) | |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2021-09-21 |