| NPI | 1053504977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60412924) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: HI DOS-1004) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2022-01197) | |
| Enumeration Date | 2007-08-23 |
| Last Update Date | 2025-10-07 |