| NPI | 1255075842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS23814) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10078457) |
| Enumeration Date | 2022-04-21 |
| Last Update Date | 2026-08-11 |