| NPI | 1598747735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 12860233-1205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NV 12023) |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2022-10-20 |