| NPI | 1902951809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101005206) |
| Additional Taxonomies | 204C00000X Neuromusculoskeletal Medicine, Sports Medicine (Licence: MI JS005206) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2019-03-20 |