| NPI | 1902268113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 82959) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2018-00506) |
| Enumeration Date | 2016-03-26 |
| Last Update Date | 2024-04-26 |