| NPI | 1689967192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WV 26398) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 26398) |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2024-09-18 |