NPI | 1568874691 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 52297) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 200814) |
Enumeration Date | 2014-05-23 |
Last Update Date | 2023-03-07 |