| NPI | 1386906352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: GA 67990) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 67990) |
| Enumeration Date | 2012-06-14 |
| Last Update Date | 2020-07-10 |