| NPI | 1629489935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA OS017851) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS017851) |
| Enumeration Date | 2014-05-08 |
| Last Update Date | 2021-10-05 |