| NPI | 1831477330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CT 054821) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 6591) |
| 207Q00000X Family Medicine (Licence: PA MD452684) | |
| Enumeration Date | 2011-08-01 |
| Last Update Date | 2017-04-05 |