| NPI | 1760822001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: WI 69454) |
| Additional Taxonomies | 208D00000X General Practice (Licence: ND RL12882) |
| Enumeration Date | 2013-07-01 |
| Last Update Date | 2018-08-24 |