| NPI | 1457388621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102201454) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 49669) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS12503) | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2022-11-23 |