| NPI | 1609137140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 86941) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX Q5992) |
| Enumeration Date | 2012-05-31 |
| Last Update Date | 2021-09-13 |