| NPI | 1730620055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD61492231) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MD D0092575) |
| Enumeration Date | 2017-03-20 |
| Last Update Date | 2024-01-16 |