| NPI | 1104822170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: OH 35062153) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC 40559) |
| Enumeration Date | 2005-06-24 |
| Last Update Date | 2019-07-23 |