| NPI | 1386262863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101281739) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND RL16543) |
| Enumeration Date | 2020-07-10 |
| Last Update Date | 2026-09-14 |