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 |