| NPI | 1649891318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CA 20A23100) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ R3371) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 010082) | |
| Enumeration Date | 2020-05-04 |
| Last Update Date | 2025-04-11 |