| NPI | 1558672212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2012-00639) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 164801) |
| Enumeration Date | 2010-06-28 |
| Last Update Date | 2021-10-14 |