| NPI | 1750886636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-02295) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NC 2019-02295) |
| Enumeration Date | 2018-03-24 |
| Last Update Date | 2024-03-25 |