| NPI | 1861979312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WV 4613) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: WV 4613) |
| Enumeration Date | 2018-07-26 |
| Last Update Date | 2025-07-10 |