| NPI | 1952716508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME140165) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: PA MD461314) |
| 207Q00000X Family Medicine (Licence: SC 36872) | |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2026-02-18 |