| NPI | 1548729734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 11837358-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 11837358-1204) |
| Enumeration Date | 2019-03-18 |
| Last Update Date | 2023-08-15 |