| NPI | 1417486937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: VA 0102206661) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT018122) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2021-07-26 |