| NPI | 1245887355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX U2262) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10071480) |
| Enumeration Date | 2019-08-22 |
| Last Update Date | 2025-01-13 |