| NPI | 1811564776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CA 20A24331) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OT020938) |
| Enumeration Date | 2021-06-09 |
| Last Update Date | 2026-02-25 |