| NPI | 1366731648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: ME MD21013) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD453023) |
| 207RS0010X Internal Medicine Sports Medicine (Licence: ME MD21013) | |
| Enumeration Date | 2011-04-07 |
| Last Update Date | 2019-01-23 |