| NPI | 1609073865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: GA 85471) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ 40602) |
| 207QS0010X Family Medicine Sports Medicine (Licence: AZ 40602) | |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2020-08-25 |