| NPI | 1912018979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: WA MD00048200) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA ML20008061) |
| 207QS0010X Family Medicine Sports Medicine (Licence: IL 036.134364) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2016-05-02 |