| NPI | 1407975865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX N4411) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: MN 50401) |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2015-12-10 |