| NPI | 1912018979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WA md00048200) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: IL 036.134364) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2025-07-24 |