| NPI | 1770648123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 38108) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 38108) |
| Enumeration Date | 2006-12-26 |
| Last Update Date | 2011-09-28 |