| NPI | 1528684339 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WY 14933A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 14933A) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: TX 14933A) | |
| Enumeration Date | 2020-06-18 |
| Last Update Date | 2025-04-09 |