| NPI | 1598874430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: WA 00019290) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: ID M-9354) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2009-08-19 |