| NPI | 1679677819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NC 2000-01433) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 200001433) |
| Enumeration Date | 2006-09-08 |
| Last Update Date | 2021-09-22 |