| NPI | 1730593930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: ND 14092) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND RL13308) |
| 207QS0010X Family Medicine Sports Medicine (Licence: MN 62097) | |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2020-10-08 |