| NPI | 1659363513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 3202) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: AZ 3202) |
| 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: AZ 3202) | |
| Enumeration Date | 2005-08-17 |
| Last Update Date | 2007-07-29 |