| NPI | 1679612618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 37296) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: AZ 37296) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 37296) | |
| Enumeration Date | 2007-02-06 |
| Last Update Date | 2020-01-10 |