| NPI | 1467988014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-00765) |
| Additional Taxonomies | 207RS0010X Internal Medicine, Sports Medicine (Licence: NC 2021-00765) |
| Enumeration Date | 2017-05-02 |
| Last Update Date | 2025-07-08 |