| NPI | 1114423720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2022-01550) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 52647) |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2023-09-20 |