| NPI | 1942512959 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: GA 78628) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: FL ME127250) |
| Enumeration Date | 2010-07-07 |
| Last Update Date | 2022-10-04 |