| NPI | 1134707128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 011651) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: KS 94-11977) |
| Enumeration Date | 2021-03-31 |
| Last Update Date | 2026-06-23 |