| NPI | 1770997884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MN 78915) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101021186) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: MI 5101021186) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WI 81783) | |
| Enumeration Date | 2014-06-17 |
| Last Update Date | 2025-08-28 |