| NPI | 1598022394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2015-01724) |
| Additional Taxonomies | 207RS0010X Internal Medicine, Sports Medicine (Licence: NC 2015-01724) |
| Enumeration Date | 2012-04-18 |
| Last Update Date | 2025-09-07 |