| NPI | 1356796601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME133818) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL MD.38125) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: AL MD.38125) | |
| Enumeration Date | 2016-04-24 |
| Last Update Date | 2020-08-28 |