| NPI | 1063862977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-1351) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: ID O-1351) |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2026-04-01 |