| NPI | 1962018671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NV CL0963) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: FL OS21760) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: CA 20A24512) | |
| Enumeration Date | 2020-09-17 |
| Last Update Date | 2026-06-26 |