| NPI | 1922084284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: ND 10460) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 46850-020) |
| 207Q00000X Family Medicine (Licence: MN 42654) | |
| 207Q00000X Family Medicine (Licence: AK 5007) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MT 10756) | |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2020-12-01 |