| NPI | 1568430015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60577630) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: IL 036-106890) |
| 207Q00000X Family Medicine (Licence: CO 45575) | |
| 207Q00000X Family Medicine (Licence: WI 42695-020) | |
| Enumeration Date | 2006-03-10 |
| Last Update Date | 2015-08-31 |