| NPI | 1780684316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD00037317) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD00037317) |
| Enumeration Date | 2005-07-26 |
| Last Update Date | 2012-07-12 |