| NPI | 1508009929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CO 49253) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 8350096-1205) |
| Enumeration Date | 2009-04-15 |
| Last Update Date | 2021-07-15 |