| NPI | 1790739092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 49997) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: CO 48888) |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2015-10-21 |