| NPI | 1447647771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: CA 20A18479) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID O-1130) |
| 207QS0010X Family Medicine Sports Medicine (Licence: TX S2984) | |
| Enumeration Date | 2015-04-24 |
| Last Update Date | 2020-09-28 |