| NPI | 1962149997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 88139) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 61732) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: KY 61732) | |
| Enumeration Date | 2022-05-20 |
| Last Update Date | 2026-07-20 |