| NPI | 1497701841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 1650) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 25468) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: IA 25468) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: SD 1650) | |
| Enumeration Date | 2006-05-26 |
| Last Update Date | 2022-08-31 |