| NPI | 1952309825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NY 212440) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: CA 20A7988) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2020-09-01 |