| NPI | 1699061317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX P7485) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX P7485) |
| Enumeration Date | 2011-06-21 |
| Last Update Date | 2022-01-26 |