| NPI | 1629516547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NY 316950) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NJ 25MB11472800) |
| Enumeration Date | 2017-02-11 |
| Last Update Date | 2024-04-19 |