| NPI | 1104029917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 34008458) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 1088) |
| 207Q00000X Family Medicine (Licence: NC 200600893) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: OH 34008458) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: SC 1088) | |
| 207QS0010X Family Medicine, Sports Medicine (Licence: NC 200600893) | |
| Enumeration Date | 2007-06-08 |
| Last Update Date | 2022-01-25 |