| NPI | 1164106886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 3044) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: CO DR.0076976) |
| Enumeration Date | 2023-06-13 |
| Last Update Date | 2026-02-15 |