| NPI | 1972831469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX J7444) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.066505) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 130781) | |
| Enumeration Date | 2009-11-23 |
| Last Update Date | 2009-11-23 |