| NPI | 1013951003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NC 39438) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 20342) |
| 207QS0010X Family Medicine Sports Medicine (Licence: NC 20342) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2025-08-28 |