| NPI | 1720469083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 29984) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NV 19734) |
| Enumeration Date | 2015-06-12 |
| Last Update Date | 2021-02-22 |