| NPI | 1417694050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX U9564) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX U95564) |
| Enumeration Date | 2022-05-16 |
| Last Update Date | 2026-07-16 |