| NPI | 1578560769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX G5751) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MS 16858) |
| Enumeration Date | 2005-07-01 |
| Last Update Date | 2023-03-07 |