| NPI | 1770761603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101248946) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2007-00785) |
| Enumeration Date | 2008-02-01 |
| Last Update Date | 2011-04-05 |