| NPI | 1518113646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 56538) |
| Additional Taxonomies | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: VA 0101246016) |
| Enumeration Date | 2008-08-08 |
| Last Update Date | 2017-06-21 |