| NPI | 1669854618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX s4789) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 29916) |
| Enumeration Date | 2015-06-26 |
| Last Update Date | 2025-07-29 |