| NPI | 1659507507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME115920) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 27182) |
| Enumeration Date | 2009-06-05 |
| Last Update Date | 2018-06-15 |