| NPI | 1356832281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME175536) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ 1908R76807) |
| Enumeration Date | 2018-05-26 |
| Last Update Date | 2026-01-30 |