| NPI | 1043745375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2025-02829) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2025-02829) |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.143319) | |
| Enumeration Date | 2017-04-24 |
| Last Update Date | 2025-08-22 |