| NPI | 1902060833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 9010A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301092823) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WY 9010A) | |
| Enumeration Date | 2008-07-10 |
| Last Update Date | 2022-10-28 |