| NPI | 1366753261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX P9126) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX P9126) |
| Enumeration Date | 2010-06-24 |
| Last Update Date | 2026-05-24 |