| NPI | 1063414480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.120017) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: AZ 30501) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2018-05-30 |