| NPI | 1265176747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 4301511136) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301511136) |
| Enumeration Date | 2022-04-21 |
| Last Update Date | 2025-06-30 |