| NPI | 1639513344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS12142) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: FL os12142) |
| Enumeration Date | 2013-04-24 |
| Last Update Date | 2025-03-21 |