| NPI | 1720379829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 074328) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 57728) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TN 57728) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: GA 074328) | |
| Enumeration Date | 2011-04-22 |
| Last Update Date | 2018-08-28 |