| NPI | 1922634039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: KY 61156) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: AR E-16196) |
| Enumeration Date | 2020-03-20 |
| Last Update Date | 2025-12-02 |