| NPI | 1508243197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: CA A174968) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101261426) |
| 207Q00000X Family Medicine (Licence: CA A174968) | |
| Enumeration Date | 2015-05-03 |
| Last Update Date | 2023-01-31 |