| NPI | 1730561655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NC 2016-02394) |
| Additional Taxonomies | 208600000X Surgery (Licence: GA 7580) |
| 208D00000X General Practice (Licence: NC 2016-02394) | |
| Enumeration Date | 2015-06-27 |
| Last Update Date | 2018-03-02 |