| NPI | 1942615471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: CO 60838) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO 60838) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2025-07-27 |