| NPI | 1659317998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CT 002058) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CT 002058) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2010-12-29 |