| NPI | 1316515364 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2025036716) | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 9032) | 
| 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2025036716) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: IA 52945) | |
| Enumeration Date | 2021-06-16 | 
| Last Update Date | 2025-09-03 |