| NPI | 1568874691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 52297) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 200814) |
| Enumeration Date | 2014-05-23 |
| Last Update Date | 2023-03-07 |