| NPI | 1154825552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: NC 201902726) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 201902726) |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2024-06-28 |