| NPI | 1174013742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX W2238) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX W2238) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2026-06-11 |