| NPI | 1104492560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101028046) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014925) |
| Enumeration Date | 2021-05-27 |
| Last Update Date | 2024-07-03 |