| NPI | 1376958728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2018021465) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2108021465) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2018021465) | |
| Enumeration Date | 2014-06-24 |
| Last Update Date | 2021-01-16 |