| NPI | 1730446022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 56505) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 56505) |
| Enumeration Date | 2012-04-12 |
| Last Update Date | 2021-03-11 |