| NPI | 1760480974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301056302) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301055302) |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2018-01-25 |