| NPI | 1629212972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: LA MD.205635) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN 13458) |
| Enumeration Date | 2009-04-29 |
| Last Update Date | 2022-08-26 |