| NPI | 1871080606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CA W20A21509) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 21509) |
| Enumeration Date | 2018-04-17 |
| Last Update Date | 2026-07-20 |