| NPI | 1417481326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX S5696) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: LA 321255) |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2023-12-12 |