| NPI | 1912931676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 40778) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MA 228934) |
| 207Q00000X Family Medicine (Licence: CO 45959) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: CO 45959) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: IA 40778) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2018-04-11 |