| NPI | 1700055621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 51273) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 51273-020) |
| Enumeration Date | 2008-02-25 |
| Last Update Date | 2011-10-05 |