| NPI | 1982679924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME107035) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: DE C10D00942) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: DE C10D00942) | |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2021-05-11 |