| NPI | 1922505676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101279918) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 93979) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: LA 333412) | |
| 207Q00000X Family Medicine (Licence: LA 333412) | |
| Enumeration Date | 2018-04-10 |
| Last Update Date | 2025-12-04 |