| NPI | 1366646192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: KY 44777) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 44777) |
| 207QS0010X Family Medicine Sports Medicine (Licence: WV 24275) | |
| Enumeration Date | 2007-06-14 |
| Last Update Date | 2021-11-17 |