| NPI | 1871561092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: CT 022901) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CT 022901) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2013-07-26 |