| NPI | 1982054557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: VA 0101263136) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116029183) |
| Enumeration Date | 2016-06-15 |
| Last Update Date | 2025-10-09 |