| NPI | 1053938852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 76922) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL83309) |
| Enumeration Date | 2020-06-29 |
| Last Update Date | 2024-07-19 |