| NPI | 1558658211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: LA MD208083) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME119064) |
| Enumeration Date | 2011-07-01 |
| Last Update Date | 2015-09-03 |