| NPI | 1699061564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101019343) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101019343) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2026-03-04 |