| NPI | 1063482669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0116027999) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0102204665) |
| Enumeration Date | 2006-01-25 |
| Last Update Date | 2025-12-11 |