| NPI | 1962768895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2016-01233) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NJ 25MA10243800) |
| Enumeration Date | 2012-04-04 |
| Last Update Date | 2025-06-06 |