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 |