| NPI | 1679957427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 58675) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NV LL2644) |
| 207Q00000X Family Medicine (Licence: AZ 58675) | |
| Enumeration Date | 2015-07-10 |
| Last Update Date | 2026-06-25 |