| NPI | 1790280683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP61148436) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL UO6061) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: WA OP61148436) | |
| Enumeration Date | 2018-03-24 |
| Last Update Date | 2025-11-10 |