| NPI | 1629418462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 87797) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1374) |
| 207QS0010X Family Medicine Sports Medicine (Licence: IL 036.144319) | |
| 207QS0010X Family Medicine Sports Medicine (Licence: LA 327457) | |
| 207Q00000X Family Medicine (Licence: IL 036.144319) | |
| Enumeration Date | 2013-06-25 |
| Last Update Date | 2022-10-05 |