| NPI | 1821021429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QG0300X Family Medicine, Geriatric Medicine (Licence: FL 30493) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 41950) |
| 207QG0300X Family Medicine, Geriatric Medicine (Licence: WI 41950) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WI 41950) | |
| 207Q00000X Family Medicine (Licence: FL 30494) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL 30494) | |
| Enumeration Date | 2006-07-08 |
| Last Update Date | 2023-03-07 |