| NPI | 1679837520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 81754) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2016025179) |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2021-06-30 |