| NPI | 1548243066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CT 47308) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 33841) |
| Enumeration Date | 2005-11-29 |
| Last Update Date | 2022-09-26 |