| NPI | 1578546065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MD D0073797) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 43792) |
| Enumeration Date | 2005-11-29 |
| Last Update Date | 2012-11-20 |