| NPI | 1427390483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101256963) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: VA 0101256963) | |
| Enumeration Date | 2013-03-18 |
| Last Update Date | 2024-10-22 |