| NPI | 1457937906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2025037410) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MO 2025037410) |
| Enumeration Date | 2021-03-23 |
| Last Update Date | 2025-09-24 |