| NPI | 1972866283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: TX P8872) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10044610) |
| 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: TX P8872) | |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2022-10-22 |