| NPI | 1467773564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2013-00283) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2013-00283) |
| 207Q00000X Family Medicine (Licence: VA 0102203100) | |
| Enumeration Date | 2010-06-13 |
| Last Update Date | 2023-12-06 |