| NPI | 1730538604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 283910) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MA 283910) |
| 207Q00000X Family Medicine (Licence: TX BP10057233) | |
| Enumeration Date | 2016-06-10 |
| Last Update Date | 2026-06-29 |