| NPI | 1912293572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA OP61106819) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: ID O-1908) |
| Enumeration Date | 2011-06-22 |
| Last Update Date | 2023-11-16 |