| NPI | 1639132111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 35751) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NY 187321) |
| 207QA0505X Family Medicine Adult Medicine (Licence: NC 35751) | |
| Enumeration Date | 2006-04-07 |
| Last Update Date | 2023-11-02 |