| NPI | 1174615017 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208VP0000X  (Licence: CT 049078)  | 
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: CT 049078)  | 
| 207PS0010X Emergency Medicine, Sports Medicine (Licence: CT 049078)  | |
| Enumeration Date | 2006-09-29 | 
| Last Update Date | 2025-10-29 |