| NPI | 1912312489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301105960) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301105960) |
| Enumeration Date | 2014-06-24 |
| Last Update Date | 2026-02-10 |