| NPI | 1376732628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101241301) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: VA 0101241301) |
| Enumeration Date | 2007-10-22 |
| Last Update Date | 2016-05-31 |