| NPI | 1699266791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: UT 7205746-8904) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS16862) |
| Enumeration Date | 2018-05-24 |
| Last Update Date | 2022-11-17 |