| NPI | 1871619965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 5101015731) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101015731) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2023-11-27 |