| NPI | 1033572003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NJ 25MB12739700) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 83531) |
| 207QS0010X Family Medicine Sports Medicine (Licence: NC 2024-00925) | |
| Enumeration Date | 2016-03-29 |
| Last Update Date | 2025-06-13 |