| NPI | 1487383238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: ID 2481401) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IN 11022165A) |
| 207Q00000X Family Medicine (Licence: NC 2025-01574) | |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2026-04-08 |