| NPI | 1952599433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101277021) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101277021) |
| 171000000X Military Health Care Provider (Licence: VA 0101277021) | |
| Enumeration Date | 2007-10-09 |
| Last Update Date | 2025-08-19 |