| NPI | 1700083045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME120806) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MD D73456) |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2022-05-16 |