| NPI | 1366640484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MT 12629) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MR-0925) |
| 207Q00000X Family Medicine (Licence: ID M-10516) | |
| Enumeration Date | 2007-07-10 |
| Last Update Date | 2019-12-02 |