| NPI | 1962853473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA O5022640) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 324676) |
| 207Q00000X Family Medicine (Licence: MI 5151012035) | |
| 207Q00000X Family Medicine (Licence: MI 5101022769) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: LA 324676) | |
| Enumeration Date | 2016-06-27 |
| Last Update Date | 2023-07-11 |