| NPI | 1699061895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME128655) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AL MD.34279) |
| Enumeration Date | 2011-06-26 |
| Last Update Date | 2016-08-08 |