| NPI | 1679787493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 41749) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 41749) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2022-06-08 |