| NPI | 1396088076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS018740) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 3076) |
| 207Q00000X Family Medicine (Licence: MI 5101020722) | |
| 207Q00000X Family Medicine (Licence: VA 0102204435) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: LA 336244) | |
| Enumeration Date | 2013-04-01 |
| Last Update Date | 2023-05-09 |