| NPI | 1497731194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 39673-20) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WI 39673-020) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2022-04-26 |