| NPI | 1699405167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5151015764) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5151015764) |
| Enumeration Date | 2022-06-16 |
| Last Update Date | 2025-11-04 |