| NPI | 1649208240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 56245) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2007025192) |
| 207Q00000X Family Medicine (Licence: MN 56245) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-03-09 |