| NPI | 1407141948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA MD60358064) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 62508-20) |
| Enumeration Date | 2011-06-13 |
| Last Update Date | 2025-07-24 |