| NPI | 1912400953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine Sports Medicine (Licence: AL 3289) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 3289) |
| Enumeration Date | 2018-03-15 |
| Last Update Date | 2024-05-16 |