| NPI | 1518163542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101244684) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2022-01008) |
| Enumeration Date | 2007-06-26 |
| Last Update Date | 2024-01-03 |