| NPI | 1508283995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AR E-10752) |
| Additional Taxonomies | 281P00000X Chronic Disease Hospital (Licence: TX BP10031139) |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2018-06-28 |