| NPI | 1124049259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: LA 344523) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA MD00020810) |
| Enumeration Date | 2006-07-22 |
| Last Update Date | 2026-05-04 |