| NPI | 1417959925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX P4166) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101237822) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2020-05-04 |