| NPI | 1356450191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2004022187) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2004022187) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2019-07-30 |