| NPI | 1821226937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0116021714) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102203496) |
| Enumeration Date | 2009-06-26 |
| Last Update Date | 2018-11-07 |