| NPI | 1205586716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 93829) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 105096) |
| Enumeration Date | 2022-03-27 |
| Last Update Date | 2026-03-30 |