| NPI | 1689028664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2018-01731) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 218956) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2018-01731) | |
| Enumeration Date | 2016-04-15 |
| Last Update Date | 2020-10-27 |