| NPI | 1710482963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CA A200844) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.140058) |
| 207XX0005X Orthopaedic Surgery, Sports Medicine (Licence: LA 329732) | |
| Enumeration Date | 2018-03-29 |
| Last Update Date | 2025-07-01 |