| NPI | 1588121800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 94-12286) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2019-02-22 |
| Last Update Date | 2025-06-09 |