| NPI | 1699125260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301513427) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116029023) |
| Enumeration Date | 2016-06-15 |
| Last Update Date | 2025-06-03 |