| NPI | 1871856849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 1128) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1128) |
| Enumeration Date | 2012-06-24 |
| Last Update Date | 2026-07-02 |