| NPI | 1124007836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 5230245-1205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 5230245-1205) |
| 207Q00000X Family Medicine (Licence: CO 47337) | |
| Enumeration Date | 2006-01-11 |
| Last Update Date | 2026-06-15 |