| NPI | 1962898163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101267656) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101267656) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME138665) | |
| Enumeration Date | 2015-04-14 |
| Last Update Date | 2023-11-27 |