| NPI | 1164408217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 9900151) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 9900151) |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2025-01-14 |