| NPI | 1376685222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CO 48487) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX G9462) |
| Enumeration Date | 2007-02-13 |
| Last Update Date | 2010-10-01 |