| NPI | 1548608318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA OS18357) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2017-01529) |
| 207QS0010X Family Medicine Sports Medicine (Licence: NC 2017-01529) | |
| Enumeration Date | 2013-06-13 |
| Last Update Date | 2023-03-03 |