| NPI | 1609839984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2006-00849) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 22221) |
| 207Q00000X Family Medicine (Licence: NC 2006-00849) | |
| Enumeration Date | 2006-04-08 |
| Last Update Date | 2026-03-18 |