| NPI | 1912079575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: CA G45457) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: CA G45457) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2008-03-05 |