| NPI | 1528027422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME125304) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NV 11818) |
| 207Q00000X Family Medicine (Licence: NC 200200257) | |
| Enumeration Date | 2006-03-20 |
| Last Update Date | 2024-01-05 |