| NPI | 1578780201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 200801219) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 200801219) |
| 208D00000X General Practice (Licence: IN 11012608A) | |
| Enumeration Date | 2007-04-20 |
| Last Update Date | 2013-09-05 |