| NPI | 1952978678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: FL ME168464) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2021021435) |
| Enumeration Date | 2021-06-10 |
| Last Update Date | 2025-09-03 |