| NPI | 1366978611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS019590) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT017633) |
| Enumeration Date | 2017-05-05 |
| Last Update Date | 2021-12-08 |