| NPI | 1770121154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME173153) |
| Additional Taxonomies | 207QH0002X Family Medicine, Hospice and Palliative Medicine (Licence: FL ME173153) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2019-12-16 |
| Last Update Date | 2025-09-04 |