| NPI | 1568091197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME182387) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 96067) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME182387) | |
| Enumeration Date | 2020-04-06 |
| Last Update Date | 2026-09-09 |