| NPI | 1295805117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 176566-1205) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 1765661205) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2026-09-15 |