| NPI | 1700376001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME163431) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: PR 35105-R) |
| Enumeration Date | 2018-05-14 |
| Last Update Date | 2023-06-30 |