| NPI | 1710568332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: IL 036.175804) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO TL.0009445) |
| Enumeration Date | 2021-04-15 |
| Last Update Date | 2025-07-02 |