| NPI | 1760405260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2013038955) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 781) |
| 207Q00000X Family Medicine (Licence: KS 31590) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2018-10-25 |