| NPI | 1417987850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX E6970) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX E6970) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX E6970) | |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2011-05-09 |