| NPI | 1417929902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME116512) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9400205) |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2024-06-15 |