| NPI | 1902829641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9701818) |
| Additional Taxonomies | 207QG0300X Family Medicine, Geriatric Medicine (Licence: NC 9701814) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9701818) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2014-01-08 |