| NPI | 1063413524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 58031) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: OH 03-2-22901) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2020-01-30 |