| NPI | 1619217486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: CA 20A13521) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 20A13521) |
| Enumeration Date | 2013-02-15 |
| Last Update Date | 2025-09-02 |