| NPI | 1962536516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9801257) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 9801257) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: SC 28120) | |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2021-10-29 |