| NPI | 1497174478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101021118) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS14806) |
| Enumeration Date | 2014-04-07 |
| Last Update Date | 2026-07-01 |