| NPI | 1962622258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 51053) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 51053) |
| Enumeration Date | 2007-04-27 |
| Last Update Date | 2021-03-11 |