| NPI | 1811967235 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: LA 324896)  | 
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX K-O568)  | 
| Enumeration Date | 2006-01-26 | 
| Last Update Date | 2022-04-18 |