| NPI | 1700959525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101265009) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE BT9852941) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2020-10-22 |