| NPI | 1053859108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-01352) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 91385) |
| 207Q00000X Family Medicine (Licence: OH 34.014117) | |
| Enumeration Date | 2017-02-09 |
| Last Update Date | 2024-07-01 |