| NPI | 1154736924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IN 01076109A) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207QS0010X Family Medicine Sports Medicine (Licence: IN 01076109A) | |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2020-12-21 |