| NPI | 1972942308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: SC 35907) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL35907) |
| Enumeration Date | 2013-06-19 |
| Last Update Date | 2026-01-19 |