| NPI | 1851687362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA MD459798) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: VA 0101255944) |
| Enumeration Date | 2011-06-22 |
| Last Update Date | 2017-04-18 |