| NPI | 1952807224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 2102) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 2102) |
| Enumeration Date | 2018-04-04 |
| Last Update Date | 2026-08-04 |