| NPI | 1407343767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 32087) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 32087) |
| Enumeration Date | 2018-04-21 |
| Last Update Date | 2024-05-21 |