| NPI | 1609848134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: KY 36747) |
| Additional Taxonomies | 207PS0010X Emergency Medicine Sports Medicine (Licence: IN 01032896A) |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2018-08-15 |