| NPI | 1902924871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2010-02095) |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine (Licence: NC 2010-02095) |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2023-12-18 |