| NPI | 1164928859 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-01975) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2021-01975) |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2025-02-07 |