| NPI | 1669769337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD60465979) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD60465979) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 47434) | |
| Enumeration Date | 2011-07-01 |
| Last Update Date | 2018-03-17 |