| NPI | 1710113733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2012-01633) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2012-01633) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WV 2612) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102203069) | |
| Enumeration Date | 2009-06-04 |
| Last Update Date | 2018-11-12 |