| NPI | 1588635932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101013758) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101013758) |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2018-01-25 |