| NPI | 1790910446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: ND 11801) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND TRL11212) |
| Enumeration Date | 2009-05-26 |
| Last Update Date | 2022-11-05 |