| NPI | 1356563969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2010-00166) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NC 2010-00166) |
| 207QS0010X Family Medicine Sports Medicine (Licence: SC 28838) | |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2010-11-10 |