| NPI | 1801457064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MS 37133) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AL 41796) |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2026-08-10 |