| NPI | 1689847568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME126491) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036128480) |
| 207Q00000X Family Medicine (Licence: CA A119932) | |
| 207Q00000X Family Medicine (Licence: MN 53001) | |
| Enumeration Date | 2008-04-10 |
| Last Update Date | 2023-09-12 |