| NPI | 1063772739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: OH 35.125926) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.125926) |
| Enumeration Date | 2012-05-29 |
| Last Update Date | 2025-07-02 |