| NPI | 1710627617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: TX W8428) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2025-01850) |
| Enumeration Date | 2022-03-30 |
| Last Update Date | 2026-09-02 |