| NPI | 1326629502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 103754) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX U1958) |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2026-04-16 |