| NPI | 1639154198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2014-01480) |
| Additional Taxonomies | 207QA0000X Family Medicine, Adolescent Medicine (Licence: NC 2014-01480) |
| 207QA0505X Family Medicine, Adult Medicine (Licence: NC 2014-01480) | |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: NC 2014-01480) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2014-01480) | |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2021-05-06 |