| NPI | 1962857227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NY 309680) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: VT 042.0040581) |
| Enumeration Date | 2016-04-24 |
| Last Update Date | 2026-08-17 |