| NPI | 1720287980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CO 043907) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: SC LL1095) |
| Enumeration Date | 2007-07-17 |
| Last Update Date | 2021-06-21 |