| NPI | 1508283995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX R2278) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AR E-10752) |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2025-10-15 |