| NPI | 1679950562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA MD463546) |
| Additional Taxonomies | 207RS0010X Internal Medicine Sports Medicine (Licence: NY 297977) |
| 207Q00000X Family Medicine (Licence: NY 297977) | |
| Enumeration Date | 2015-04-30 |
| Last Update Date | 2023-03-22 |