| NPI | 1700118890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX Q0418) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL32336) |
| 207QS0010X Family Medicine Sports Medicine (Licence: SC 32336) | |
| Enumeration Date | 2010-02-01 |
| Last Update Date | 2017-01-10 |