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 |