| NPI | 1770874117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 55294) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 55294) |
| 207RS0010X Internal Medicine, Sports Medicine (Licence: MN 55294) | |
| Enumeration Date | 2011-04-20 |
| Last Update Date | 2023-06-14 |