| NPI | 1629127915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-01557) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 45762) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2019-01557) | |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2025-01-02 |