| NPI | 1780910364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS10979) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TN 2081) |
| Enumeration Date | 2009-11-02 |
| Last Update Date | 2022-02-16 |