| NPI | 1629241427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME114102) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 093133) |
| Enumeration Date | 2008-04-11 |
| Last Update Date | 2012-12-02 |