| NPI | 1457842965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: MI 5101028209) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NY 318582) |
| Enumeration Date | 2018-05-21 |
| Last Update Date | 2024-08-30 |