| NPI | 1821478769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: WI 71910-20) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: KY 51293) |
| Enumeration Date | 2015-06-05 |
| Last Update Date | 2023-10-04 |