| NPI | 1942567086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 13903) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 63192) |
| Enumeration Date | 2012-04-13 |
| Last Update Date | 2023-03-04 |