| NPI | 1710568670 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TX U2293) | 
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX 3046123513) | 
| Enumeration Date | 2021-04-20 | 
| Last Update Date | 2025-08-19 |