| NPI | 1558634915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: UT 4860583-8905) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: MT MED-PHYS-LIC-26324) |
| 207Q00000X Family Medicine (Licence: CA A 121977) | |
| Enumeration Date | 2012-02-16 |
| Last Update Date | 2021-09-30 |