| NPI | 1578971800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 04326) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 04326) |
| Enumeration Date | 2014-07-30 |
| Last Update Date | 2024-02-27 |