| NPI | 1972178630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: PA OS024150) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA OS024150) |
| 207Q00000X Family Medicine (Licence: PA HS000029L) | |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2025-06-01 |