| NPI | 1912119967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: PA MD449496) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD449496) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2025-08-15 |