| NPI | 1740626795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX Q4946) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: PA MD462194) |
| Enumeration Date | 2013-05-17 |
| Last Update Date | 2022-06-16 |