| NPI | 1831714211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: GA 94989) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 11978) |
| Enumeration Date | 2020-06-11 |
| Last Update Date | 2024-08-15 |