| NPI | 1679991178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS020357) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2017014793) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2020-08-24 |