| NPI | 1780947044 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: OR DO163283) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR DO163283) |
| 207Q00000X Family Medicine (Licence: OR PG158947) | |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2022-03-02 |