| NPI | 1780909606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2080S0010X Pediatrics Sports Medicine (Licence: FL ME138351) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 35992) |
| 207QS0010X Family Medicine Sports Medicine (Licence: NY 276592) | |
| Enumeration Date | 2010-04-03 |
| Last Update Date | 2019-01-24 |