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 |