| NPI | 1881629202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: ID M-12444) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: SD 4025) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2015-04-15 |