| NPI | 1912215112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: DE C2-0010185) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS015269) |
| Enumeration Date | 2010-09-22 |
| Last Update Date | 2014-04-28 |