| NPI | 1801391362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 57116) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 63903) |
| 207Q00000X Family Medicine (Licence: KY 57116) | |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2025-05-06 |