| NPI | 1861787814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 64193) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 55271) |
| 207Q00000X Family Medicine (Licence: WI 64193) | |
| Enumeration Date | 2011-06-17 |
| Last Update Date | 2022-06-15 |