| NPI | 1790121804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KS 04-38168) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 9408115) |
| Enumeration Date | 2013-05-15 |
| Last Update Date | 2016-07-05 |