| NPI | 1508150830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KS 04-37926) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2015028100) |
| Enumeration Date | 2011-06-03 |
| Last Update Date | 2023-08-09 |