| NPI | 1619269222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 5101019138) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101019138) |
| Enumeration Date | 2011-05-15 |
| Last Update Date | 2017-12-12 |