| NPI | 1790047918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 4301506248) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 27602) |
| 207QS0010X Family Medicine Sports Medicine (Licence: VA 0101264969) | |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2024-02-07 |