| NPI | 1760610547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-00468) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD446930) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: PA MD446930) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2019-00468) | |
| Enumeration Date | 2009-06-30 |
| Last Update Date | 2025-02-11 |