| NPI | 1770997942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 92330) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: TX R8652) |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2025-09-15 |