| NPI | 1104820968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA OS015993) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34002980) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2016-06-13 |