| NPI | 1104274950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID M-14112) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MRM-1581) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: ID M-14112) | |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2025-11-05 |