| NPI | 1669531604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 25617) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101239014) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: CA 153246) | |
| Enumeration Date | 2006-12-06 |
| Last Update Date | 2021-09-29 |