| NPI | 1720648066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SD 14182) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 67722) |
| 207Q00000X Family Medicine (Licence: MN 30237) | |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2026-04-22 |